Methods: As part of a larger study on integrated care, a team of researchers conducted individual interviews (n=8) and a series of focus groups (two with each group of participants, n=15) with adults diagnosed with a serious mental illness (schizophrenia spectrum disorders: 4, major depressive disorder: 10, bipolar disorder: 6, other: 3). All interviews were recorded, transcribed verbatim, and entered into NVivo qualitative software for thematic analysis. Three researchers read all transcripts and developed a codebook collaboratively; the final codebook was used to recode the transcripts, and one-third of the transcripts (n=4) were double coded by two researchers, with all discrepancies resolved by consensus. All research activities were approved by the state IRB.
Findings: Barriers to accessing primary care included: “intertia” of depression, psychosocial sequelae of homelessness, environmental barriers and safety at public transportation stops, and lack of trust in medical providers associated with mental health stigma. Facilitators of accessing primary care included: behavioral health providers vouching for primary care providers, fear of untreated medical conditions, and understanding why medical care is important. Other salient themes identified by participants included unstable housing and homelessness as barriers to taking medications due to: lack of storage and access to medications, inability to cope with side effects while unstably housed, and safety-related consequences of deeper sleep and vivid dreams resulting in decreased alertness or physical reactions upon waking.
Conclusion and Implications: Medicaid transformation initially calls for increased process-oriented metrics of screening and provision of care. However, changing diabetes and hypertension outcomes for adults with serious mental illness may require additional support from behavioral health workers to resolve barriers to accessing care and engaging in recommended health behaviors. As a prerequisite to improved diabetes and hypertensive outcomes, providers may have to prioritize support to resolve homelessness, challenges with transportation, and symptoms of depression. Furthermore, behavioral health providers may need to leverage their relationship with adults with psychiatric disabilities to support the development of a new relationship with a primary care provider.